NURSING NUR 2811 VERSION 3 SUMMARY - study guide

1. SATA. Older male in ER has become increasingly confused in 3 days; nursing action? ­ Determine oxygen saturation rate and breath sounds. ­ Evaluate polypharmacy for possible drug interactions. ­ Obtain urine and sensitivity for possible UTI. 2. Pt. with bipolar disorder reports not taking his Depakote for 6 mo; nurse assessment? ­ Affect 3. Female pt. with pyelonephritis is concerned about dialysis; nurse best initial response? ­ Explain the relationship between chronic kidney infection, renal failure, and dialysis. 4. Sickle cell c/o pain in fingers; underlying pathophysiology for pain in sickle cell crisis? ­ Sickled red blood cells do not flow through small blood vessels leading to vasocclusion and ischemia. 5. Pt. at clinical reports new onset of pyrosis and dyspepsia; action has highest priority? ­ ​ Instruct the client about the side effects of reflux disease. 6. Pt. bathing with inelastic skin turgor, large pendulous breasts, and a soft, flaccid abdomen. ­ Teach the client to dry the skin well between skin folds. 7. Which symptom is characteristic of ureteral colic in the client diagnosed with renal calculi? ­ Chills, fever, and dysuria. 8. Suspected Guillian­Barre syndrome; which comment is significant to diagnosis? ­ “About two weeks ago, I missed a day at work because I had a bad cold. 9. Pt. with burns to posterior neck; which intervention to prevent contractures at injury site? ­ Actively turn head from side to side 90 degrees hourly. 10. Pt. having anxiety reaction when crossing over a bay bridge; action to implement? ­ Teach client to listen to music or audio books while driving. 11. Assessing normal development of 9­month­old; information to obtain? ­ Can the child sit alone? 12. Parkinson’s meds; symptom management requires a balance among neurotransmitters? ­ Acetylcholine and dopamine. 13. Pt. with SARS returned from China in isolation; which intervention in plan of care? ­ Require use of gown, gloves, and N­95 mask. 14. DKA pt. on sliding scale regular insulin; intervention important to implement? ­ Confer with the healthcare provider about a continuous IV insulin infusion15. Teacher thinks she is pregnant (neg test at night) but is on tetracycline for acne; instructions? ­ Use first voiding of the day for accurate results of pregnancy test. 16. Child with rheumatoid arthritis has a viral infection and fever/ taking aspirin for arthritis. ­ Stop taking aspirin and give different NSAID. 17. Pt. admitted with possible head injury and spinal cord injury; priority assessment? ­ Respiratory status 18. Caring for pt. with acute MI; observation warrants immediate intervention? ­ The telemetry displays ventricular bigenminy. 19. 2 day post­total laryngectomy transferred to private room is anxious; intervention? ­ Answer the client’s call signal in person quickly after he calls. 20. Child with HF receiving Lasix with potassium of 3.0 mEq/L; important assessment? ­ Cardiac rhythm and heart rate. 21. Child coming to ER with hx of flu­like symptoms for past week; equipment to assemble? ­ Mechanical Ventilator. 22. What script anticipate for pt. with increased ICP secondary to head injury? ­ Mannitol (Osmitrol). 23. Pt. is cigarette smoker and alcohol drinker is post­cholecystectomy but tremulous, agitated, febrile, and disoriented; this is likely the finding of what? ­ Impending delirium tremors. 24. Pt. paranoia and homicidal ideation in ER saying daughter lives in TV; thought disorder? ­ Easily changes the subject. 25. Infant on Captopril for HF; which finding indicates med effectiveness? ­ Blood pressure decreased from 125/85 on admission to 106/60 today. 26. Pt. fell at home and is on labetalol and ranitidine; intervention to include in plan of care? ­ Frequent monitoring of blood pressure. 27. Pt. with mitral stenosis at 28­weeks gestation; what investigate first? ­ Persistent cough. 28. Home care of child with cystic fibrosis; parental action shows understanding? ­ Gives pancreatic enzymes before every meal and snack. 29. Child admitted with possible nephrotic syndrome; parent statement goes with diagnosis? ­ “I couldn’t get my son’s socks and shoes in this morning.”30. Pt. scheduled for laminectomy with back pain r/t intervertebral disk; preop teaching about numbness and tingling in lower extremities occurs due to? ­ Manipulation of nerves and muscles during surgery. 1) A nurse is planning care for a child who has scabies and he keeps itching… ANS: Keep nails trimmed short and have him wear mittens 2) An acute care hospital has a disaster something about an outage and a generator. The UAP asks the charge nurse what she can do to help… ANS: Tell clients to stay in their rooms 3) Discharge teaching to a patient with heart failure what parameter is most important for weight monitoring… ANS: Weigh themselves at the same time everyday 4) Patient with metabolic syndrome is going to start exercising what is most important to tell him… ANS: Monitor BP as exercise increases 6) Patient c/o pain distal to insertion site, what action should the nurse implement? ANS: Remove 7) A seriously ill patient that has a DNR is transferred to a medical facility in another state that does not honor that what should the nurse implement? ANS: Honor clients wishes 8) Question regarding taking a sample for sputum out of a water chamber from a patient with a chest tube insertion for a person on a trach, where do you take the sample from? ANS: Rubberized port at bottom of the catheter chamber 9) A patient is in the acute phase of burn to prevent auto contamination when changing dressings how should you do it? ANS: Change each dressing separately 10) The nurse enters a client’s room with his morning meds. Patient states he will take them later. What action should the nurse take? ANS: make a deal him on a time to return and give the meds 11) A client has returned from China and has SARS. What will you do before coming into contact with him? ANS: Gown, gloves, n95 mask12) A client admitted with chest tightness respiratory acidosis an increase in which lab would show this? ANS: PaCO2​ 13) Male client bladder always feels full 14) Question on palpate lymph nodes on a child which is of concern? ANS: large, warm, non­tender 15) A Patient who is diabetic has DKA and is receiving insulin using a sliding scale, his blood sugar has been 520­540. What action should the nurse take? ANS: call physician and to get order for IV insulin 16) An adult has 110 BPM what intervention should the nurse implement first? 17) A nurse makes a home visit for parents of a child with cystic fibrosis, how would the nurse know that they are following treatments at home? ANS: give pancreatic enzymes with each snack 18) Peptic ulcer disease 19) A nurse observes a mother in a hallway punishing her 3 year old child for wetting his pants, what action should the nurse take? ANS: provide toilet training pants and calming the mother 20) Laminectomy for a herniated intercerbral disc, when conducting preoperative teaching what should the nurse implement? 21) When conducting an assessment on a 6 month old infant... ANS: Keep child on your lap 22) Patient comes in vomiting… ANS: Maintain NPO status 23) A mother who is breastfeeding 2 days post­op has inverted nipples… ANS: use a breast shield 24) Smoking 2 packs a day has COPD?? 25) A male client has anxiety when driving over the bay bridge which would you suggest to help address this fear? ANS: Listen to music 26) Using the parkland formula for a patient with burns 4ml x Patients weight in kg which is 76kg x whatever % of burns, which is 40%. SO it is 4ml x 76kg x 40% = ANS: 12,160 27) Question about MONO (kissing disease) ANS: Ellen BARRE (something like that I don’t remember how to spell it!) 28) A patient with bilateral hearing aids it is ringing…ANS: have patient reinsert them 29) A patient has Guillen Bare Syndrome what would be the cause of this? ANS: Has had a cold within the last 2 weeks 30) A patient with cellulitis from an insect bite on lower right arm. You need to start an IV antibiotic... ANS: use left arm 31) A nurse is triaging from an explosion which patient would you black tag? ANS: The one that is almost dead or nearest to death, don’t remember what exactly it said though. 32) Medication one something about prescribed dose is like 60mg; available is 750mcg/per 2.4ml ANS: 0.19, round to the nearest 10th so it is 0.2 33) A nurse who usually works on a step down unit has to be moved to work on a critical care floor, which patient should you assign to this nurse? ANS: vent client who has chronic COPD 34) A child who is terminally ill and death is imminent, what is best for you to tell the parents? ANS: something about hospice 35) A patient who has just had knee surgery says he can’t transfer to bedside commode because it is too painful what should the nurse implement? ANS: Get assistive devices for weight bearing 36) A male client on palliative care can’t swallow and is dehydrated but doesn’t want an IV. What should the nurse do? ANS: keep him comfortable 37) A female client who is getting ready to go in for a biopsy is scared and wants her husband to stay with her during procedure and hold her hand. ANS: Give him gown and mask and allow him to stay with her and hold her hand 38) A bipolar client reports that he is not taking his prescribed medications… ANS: AFFECT 39) LPN and RN which client would you assign to the RN? ANS: Suicide (they need to be on one­one supervision) 40) The nurse knows that several complications can occur with transfusion, which is an indication of air emboli? 41) The nurse is caring for a client in renal failure which lab is most important to report to the HCP immediately?42) A female comes into the clinic stating she is a victim of date rape 2 days ago. What should the nurse ask first? ANS: find out if she had any consensual sex in the last couple days​ 43) A child with juvenile arthritis develops a low grade fever and is already taking aspirin. What should the nurse tell the mother to give her child? ANS: stop aspirin and give NSAIDS 44) RN assess a client one hour after administration of blood, which instruction should she provide to the UAP? ANS: Continue monitoring vitals 30 min 45) A female client with dysrhythmias, and her mag levels are down I believe. What prescription should the nurse implement first? 46) A male client is admitted ICU needs a low sodium diet. Which choice is best? ANS: Turkey salad sandwich 47) A client is admitted with partial thickness burns to the posterior neck, you don’t want them to become contracted… ANS: turn head side to side 90 degree 48) 4 new patients present into the ER within 15 minutes of each other, who do you see first? ANS: 2 year old with stridor 49) A newly diagnosed patient with systemic lupus what information would be accurate to tell this client regarding this disease? ANS: disease is characterized by periods of flare­ups and remission 50) A client is admitted with acute pancreatitis he admits drinking bourbon daily, what would you report immediately to the HCP? ANS: Confusion and Tremors 51) Postpartum unit who should the nurse assess first? ANS: saturating 2 pads in an hour 52) Question about patient being infertile and has PID what pathophysiology explains this correlation? 53) A patient has pernicious anemia husband tells the nurse that his wife has been confused the last couple of days. The nurse tells the husband... ANS: this is normal with B12 deficiency 54) Don’t know what the question is but the answer is… ANS: Ventricular bigamy 55) A patient with cirrhosis has a new onset of dyspepsia (heartburn)... ANS: tell client to see HCP56) The nurse assessing a client with sensory deficit is @ risk for falls… ANS: Reorientate client to surroundings 57) Question about patient receiving Lovastatin and something else what do you monitor for? ANS: hypokalemic 58) Hand washing question for aseptic technique… ANS: let water run down from elbows 59) A client with cirrhosis becomes confused I think ammonia levels are up… ANS: Lactulose 60) A client with Peptic ulcer disease (PUD) has an NG tube with intermittent suctioning and there is coffee like grounds. The patient c/o N/V what action should the nurse take? 61) A male client admitted to cardiac unit with sporadic premature PVC’s… 62) A female is vomiting and unable to tolerate liquids has no pain, what action should the nurse implement? ANS: Maintain NPO status 63) A client with terminal cancer has pneumonia and has no heroic measures, he has impending death… ANS: this is either keep comfortable, but if one of the choices is do not perform CPR then that is the answer so pay attention 64) A patient with compound fractures to the tibia and fibula in a traction… ANS: Assess pin sites for infection/ keep​ 65) A female client with paranoia says that her child comes out from the television and talks to her what is another indication that she has dissociative disorder? ANS: Constantly changes the subject 66) An older male client has been brought to the ER by family with onset of confusion in last 3 days... ANS: urine culture 67) A female client 40 years old who has a family history of colectoral cancer, she wants to take preventative measures… ANS: Sigmoidoscopy yearly 68) An older client admitted to rehab following a CVA has aphasia, LS paralysis, difficulty swallowing. What is most important to include in plan of care? ANS: Obtain a consult with speech therapist 69) A patient with syncope has a history of aspiration. And is drinking from a straw what should the nurse implement? ANS: Thicken liquids70) A client is recently received a prescription for ramperadl (I think I couldn’t hear it) for sleep deprivation reports side effects from the drug. Which side effect should you report to HCP? 71) Multiple response: Something about a patient using a quad cane sometimes has unsteady gait and wants to use a wheel chair, what interventions would be most important? There are 3 answers and I just remember to not pick the wheelchair ANS: Lower bed to lowest position ​ Keep things within reach 72) A nurse is speaking at a community health fair in a Hispanic community I believe about communicable diseases. What is important for the nurse? ANS: Respect their culture​ 73) A patient had a total laryngectomy 2 days ago is being transferred from ICU to whatever Unit and client is anxious, what intervention is most important? ANS: Answer call light right away 74) When obtaining isolation supplies for a client what information is most important for the nurse to obtain? ANS: how is or will the infection be transmitted (e.g. airborne, blood, contact, etc…)​ 75) A child is arriving by ambulance with flu like symptoms respirations are 16 BP 90/60, HR 168… ANS: need to start an IV 76) A patient starting on cipro IV for UTI what is the most important intervention? 77) Infant admitted for V/D vomited 25 ml, dry diaper weigh 75 kg, 1 wet diaper weighed ?, and another one? What is the I &O? ANS: 80 ml 78) Acuity of group of clients in ICU has matrix system a nurse calls off what should the charge nurse do now… ANS: client acuity mix 79) A saline lock is to be discontinued on a client who is receiving antiplatelet medication what action should the nurse implement? ANS: apply pressure for 3­5 minutes after removing 80) A patient admitted with hypopituitarism and is hypotensive and diaphoretic, what would require immediate action by the nurse? ANS: lethargy 81) Medication question: Something about 2 different meds one is Zofran for sure but anyways the order is 2mg IM for one but is available in 4ml, the other one is ordered 3mg but is available in? What is the total volume to be administered? ANS: 2ml82) Question about pneumothorax ANS: remove air 83) A male client with bipolar disorder reports to the charge nurse that he hasn’t been taking prescribed meds… ANS: Intellect of speech 84) Vfib and a defrbrillator nurse giving cpr which action should the nurse give to UAP after getting crash cart? ANS: Take over CPR 85) A client with a compound fracture with internal fixation c/o pain tingling sensations. The nurse notes has diminished pedal pulses. Based on these findings what is the patient at greatest risk for? ANS: Emboli 86) A nurse has a home visit with a client who experiencing symptoms that should be controlled by the medication prescribed, what nursing diagnosis… ANS: Innefective health maintence 87) Dischsrge instructions to a client with kidney transplant an is on immunosuppresants… ANS: Avoid large crowds 88) A patient comes in with a stage 3 decub ulcer to the coccyx, stale urine on clothes, and is living at home with son… ANS: Contact adult services 89) Picture Question: BP cuff to clients thigh where should you place the sthescope? The picture will be 2 bodies. One will be facing towards you the other facing away. You will choose the one facing away looking at his ass end and point curser on left leg behind the knee. 90) A female client comes in and tells the nurse that she may be pregnant and says she is on tetracycline for acne. What should the nurse tell her? ANS: Stop the medication 91) A client scores an 8 on post anesthiea scoring stystem.. ANS: Normal transfer patient 92) A client with rheumatoid arthritis is taking prednisone and Ibuprofen for self­management, which information should the nurse obtain to know that it is being controlled? 93) A client whom is hit n=by a car from running and dodging through traffic is admitted to ER with signs of ICP. A CT scan shows an intracerebral bleed, after evacuation of the hematoma what post op, and what is the pathophysiology for this vent setting? ANS: 94) A nurse is doing her daily assessment on a female client begins to cry to the nurse that her family hasn’t visited or called in a longtime…ANS: determine when they last visited 95) Which symptom is characteristic of renal calculi? ANS: Intense pain radiating through groin 96) A patient receives 6mg IV push of morphine c/o stinging after injection 97) A patient comes in has rapid speech, flight of ideas and says they have only slept 3 hours in last 48… 98) A patient with ICP secondary to head injury, what med… ANS: Mannitol 99) Myxedema Coma… ANS: IV with thyroid​ A patient with Parkisons disease this is because they are lacking… ​ ANS: Dopamine & Acetocholine 101) A high school football team travels on a bus together for a game, they all contact MRSA… ​ ANS: Hand Sanitizer 102) A female client frequently tells the nurse that she frequently thinks of hurting herself which question is most important to ask? ​ ANS: Taking your own life 103) 11 year old client runs away from and the therapist wants him to verbalize 3 ways to deal with things at home, what is the best to way to get him to talk… ​ ANS: playing a board game 104) Multiple Response: A nurse is teaching a patient about signs and symptoms of preeclampsia ​ ANS: Edema, Headache, blurred vision 105) A nurse manager observes a staff nurse persuading a student nurse to do her job or something like that, what should the nurse manager do… ​ ANS: A written contract 106) A patient is brought in to the ER following a motor vehicle accident, what is the highest priority? ​ ANS: Respiratory 107) DRAG N DROP: A UAP leaves the floor without permission on several occasions put in order how this should be handled… ANS: ​ Document the behavior ​ Have a private conversation ​ Set up breaks ​ Make sure she is complying108) A patient with breast cancer has just started chemo and is going to be released what statement made by her will know that she has an understanding… ​ ANS: Picks out movies and books to the pass the time at home​ 109) A Client who is post­menopausal smokes 2 packs a day and takes 150 mg of calcium. What patient teaching should nurse include about prevention for osteoporosis? ​ ANS: Increase calcium, do not pick quit smoking that was not the right answer 110) A client with mitral stenosis 28 weeks gestation which observation… 111) A male client is admitted to ER with COPD severely depressed respirations, daughter states she increased his O2 at home and then called an ambulance when his breathing got worse. What intervention will the nurse have to make? ​ ANS: Intubate 112) A male client diagnosed with schizophrenia is diaphoretic and pacing the hallway, which intervention should the nurse implement? 113) A male client with dementia admitted to the healthcare facility, which action by the UAP would need to be documented by the nurse? 114) Which question by the nurse is appropriate for the nurse to ask a patient who is taking prescribed analgesic daily for chronic pain to determine if she has built up drug tolerance? 115) A patient taking 300mg of a beta blocker (couldn’t understand the name) and Zantac, what should the nurse assess? ​ ANS: BP 116) Admission assessment of client with Guillen Barre… ​ ANS: Cold in the last 2 weeks 117) While assessing an older female client in bed who is feeding herself she has inelastic skin, laceration, what is most important I think is what it asked… I think this one might be keep skin dry in folds, but not sure 118) A patient with pyelonephritis is worried that she will have to go on dialysis for the rest of her life, how should the nurse respond… 119) Question based on these findings and you will have to look in the chart, oxytocin, stadol, and LR what action would the nurse implement? 120) A staff nurse reports to the charge nurse that there is a malfunction in a machine… ​ ANS: use another machine and compare 121) A combative old man, what nursing diagnosis is best… ​ ANS: Risk for others self­direct harm or violence 122) A male client born at 28 weeks gestation… ​ ANS: give surfactant 123) Something about heparin and lovenox with Cushing’s…124) ANS: Catopen 125) A patient is given a bronchodilator for asthma you assess in 30 min how would you determine the effectiveness? 126) A patient whom can’t swallow and is dehydrated refuses to have an IV put in he is a DNR… ​ ANS: keep comfortable 127) Question about ischemia/ GI bleed ​ ANS: hypovolemic 128) A patient in constant pain is at risk for… ​ ANS: Delirium 129) Pancreatitis ​ ANS: Confusion and tremors 130) Something about a postop patient with a urinary drainage/ clot ​ ANS make sure they are having output/ no kinks 131) Question about T waves and PVC’s ​ ANS: repolarization 132) Question about a patient in ICU… ​ ANS: MODS 133) A patient with terminal cancer comes in with pneumonia no heroic measures… ​ ANS: No CPR should be provided 134) ANS: ​ Taking a child’s BP and pulse 135) ANS: ​ dry skin between folds 136) The question with the left foot tingling, pulses diminished… ​ ANS: Compartment syndrome 137) Listening question: listen to lung sounds ​ ANS: high pitched wheezes 138) Multiple response for the elderly who is week and wants wheel chair ANS: ​ Bed in lowest position ​ Keep things in reach ​ Give direction ​ Assist client 139) Multiple response: HypopituitarismANS: ​ only get 2 though so you will need to look up ​ Hypotension ​ Bradycardia 140) Multiple response: Rheumatoid Arthritis ANS: ​ low grade fever and cough ​ Swollen and tender ​ Bruising over several areas 141) There was another question regarding juvenile rheumatoid arthritis… ​ ANS: use a warm blanket before getting them up 142) Know the patho of sickle cell anemia, I know the answer did have something in it with the word sickle cell 143) The Patient hit by a car…